AHA Scientific Sessions 2026 Abstract · Nov 2, 2026
A Comprehensive Review on the Efficacy of Antihypertensives in Patients with End-Stage Renal Disease
By Akele O, Asogwa N, Ling J et al.
Introduction/Background: Hypertension is common in end-stage renal disease (ESRD) patients receiving hemodialysis (HD) and contributes substantially to cardiovascular morbidity and mortality. Drug selection remains difficult because BP targets, dialyzability, residual kidney function, and intradialytic hemodynamics vary across studies. Research Question/Hypothesis: This review evaluated whether antihypertensive drug classes differ in BP control, cardiovascular benefit, dialyzability, and safety in adults with ESRD receiving HD. Methods/Approach: PubMed, Embase, and Web of Science were searched from inception through January 2025 using terms for hypertension, ESRD, HD, antihypertensive agents, cardiovascular disease, cardiovascular mortality, and renal replacement therapy. English-language human studies of antihypertensive treatment in ESRD were included. Case reports, editorials, opinion pieces, and non-human studies were excluded. Studies were screened by 2 reviewers, disagreements were resolved by consensus, and findings were synthesized qualitatively because of clinical and methodological heterogeneity. Results/Data: Volume and sodium control remained foundational; dietary sodium restriction reduced BP by 8.4/4.4 mmHg. Beta-blocker evidence was favorable but inconsistent: RCT-level data showed 27% lower all-cause mortality and 56% lower cardiovascular mortality, while comparative studies showed similar mortality for highly versus poorly dialyzable agents (HR 0.94, 95% CI 0.81-1.08) and fewer cardiovascular events with highly dialyzable agents (HR 0.88, 95% CI 0.83-0.93). Renin-angiotensin-aldosterone system inhibition showed mixed effects; one ARB trial reported fewer cardiovascular events versus control (19% vs 33%; adjusted HR 0.51, 95% CI 0.33-0.79; p=0.002), but broader meta-analytic data did not show consistent mortality reduction. Calcium channel blockers showed favorable pharmacokinetics and outcome signals, including fewer composite mortality/nonfatal cardiovascular events with amlodipine (15% vs 25%; HR 0.53, 95% CI 0.31-0.93; p=0.03) and lower cardiovascular mortality in a national cohort (RR 0.74, 95% CI 0.60-0.91). Diuretic benefit appeared greatest in patients with residual urine output. Direct vasodilators and clonidine reduced BP in refractory hypertension but were limited by adverse effects and sparse safety data. Conclusion(s): Antihypertensive management in ESRD should be individualized rather than class-driven. The most defensible strategy is volume-first BP management with drug choice guided by comorbidities, residual renal function, interdialytic BP, hemodynamic stability, and dialyzability. Larger randomized trials are needed to define optimal sequencing, dosing, and outcome-based BP targets in HD.